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These are images of a 47-year-old

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male who has acute loss of vision,

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and this is the non-contrast CT.

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So the first thing I'm going to do is

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look to see if there is hemorrhage or any

0:15

contraindication to thrombolysis or a

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stroke mimic tumor or something else.

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I don't really see any hemorrhage on first pass.

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I'm thinking that visual change is

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going to be in the posterior circulation.

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So I'm going to get out my

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one millimeter thick slices to look

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for a hyperdense vessel sign, and it's

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always hard in the posterior fossa.

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You get a lot of beam hardening.

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This patient has dental artifacts.

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So that's making it worse.

0:43

They don't really look like hyperdense

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vessel signs, but it's really hard to spot.

0:47

I can't tell. I'm looking at the right

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PCA. Don't really see much there.

0:52

Looking at the left PCA,

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don't really see much there.

0:55

So MCA looks okay.

0:57

I don't really see

0:57

a hyperdense vessel sign.

0:58

What about loss of gray-white differentiation?

1:01

So I'm looking at this hard to evaluate the

1:03

brainstem, but I'm noticing that in the right,

1:06

using narrow windows so I can see a little bit

1:09

better, and I'm noticing that maybe there's

1:11

some loss of gray-white differentiation

1:13

in the right mesial temporal lobe.

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And I see it again down here, the right

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occipital lobe compared to the left.

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And yeah, that looks like it's a real

1:24

finding and then I see maybe something in the

1:29

thalamus a little bit hard to tell, but it

1:31

looks like I'm losing a little density there.

1:34

I don't see anything above that.

1:36

It's always helpful to look

1:39

at other imaging planes.

1:41

I'm looking at the coronal CT.

1:42

I find this very helpful for PCA strokes.

1:45

You can see the hypodensity

1:47

for having me,

1:49

and that medial occipital lobe, and

1:51

the mesial temporal lobe, and look

1:53

at this side compared to this side.

1:54

Here's normal gray-white differentiation.

1:56

Here's that hypodensity.

1:58

It just becomes more and more apparent.

1:59

So I'm thinking, yes, maybe

2:01

a pretty big PCA stroke.

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Maybe there's a little bit in the thalamus.

2:05

I don't see much swelling yet because

2:07

it's early, so we wouldn't expect that.

2:08

So I'm going to get a CTA, CTA of

2:11

the neck was not too revealing.

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Here's the CTA of the head.

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This is a really subtle finding, but you

2:17

can see cutoff of the right T2 segment.

2:21

And that would go along with

2:23

where we saw the hypodensity.

2:24

In fact, I was looking there because that's

2:26

where I thought I'd be seeing a clot.

2:28

So this did not have a hyperdense

2:30

vessel sign, but does have

2:32

loss of gray-white differentiation

2:34

and does have a cutoff.

2:36

So the rest of the vessels looked okay.

2:40

So let's see what our MR showed.

2:43

Does in fact show that area of the

2:46

mesial temporal lobe, occipital lobe,

2:48

thalamus. So, that's not surprising.

2:51

The thalamus is usually supplied by the

2:52

thalamal perforators off the P1 segment.

2:55

So, there may have been a clot there that then

2:56

migrated and then you see all these other

2:58

smaller strokes in the right cerebellum, the

3:02

left cerebellum, a little stroke in the midbrain,

3:05

the left mesial temporal occipital region, left

3:10

border zone region, right border zone region.

3:12

These are between the MCAs and DBAs.

3:14

So now I'm seeing multiple different

3:16

kinds of vascular territories.

3:17

So I'm thinking this was probably

3:19

cardioembolic as the source.

3:21

And as I said, the neck was not too revealing,

3:23

so we didn't have a source in the neck.